Esophageal distensibility with FLIP and EoE disease severity

In patients with eosinophilic esophagitis (EoE), the development of fibrosis due to ongoing inflammation is one of the concerns as this can lead to more difficulty with swallowing,  food impactions, a smaller caliber esophagus, and stricturing.  A recent report highlights a way to measure esophageal distensibility and its correlation with disease severity (Clin Gastroenterol Hepatol 2013; 11: 1101-7).

This report describes the evaluation of 70 patients with EoE (ages 18-68 years with median of 38 years`, 50 men) who underwent endoscopy along with high-resolution impedance planimetry.  The average followup was 9.2 months. The functioning luminal imaging probe (FLIP) system was used after the endoscopy by placing a catheter transorally.  The catheter had 16 ring electrodes spaced 5-mm apart in the 8-cm measured segment.  The FLIP distal recording began 3 cm proximal to the esophageal gastric junction.  Esophageal cross-sectional areas were measured during 2-mL stepwise distentions and increasing to a maximum of 40 mL.

Patient EoE Clinical Features at baseline:

  • 26 patients had a history of food impaction
  • 37 patients had dysphagia
  • 5 patients had chest pain
  • 2 patients had heartburn
  • Ringed esophagus: 9 (13%) had severe endoscopic findings, 17 (24%) had moderate endoscopic findings, 40 (57%) had mild endoscopic findings
  • Primary treatment: PPI treatment (78%), Topical steroids (10%), diet 4 (6%)

Key findings:

  • Patients with food impaction had significantly lower distensibility plateau (DP) than those with solid dysphagia alone (see manuscript Figure 1).
  • Mean DP in food impaction 113 mm2 compared with 229 mm2 for those without a history of food impaction
  • The severity of mucosal eosinophilia did not correlate with risk for food impaction, distensibility, or requirement for dilatation.

In many ways, the findings are completely obvious.  If an individuals esophagus is less distensible, it makes sense that food could get stuck. However, the article highlights a novel way of assessing esophageal distensibility in this population.  While the study did not identify higher mucosal eosinophilia as a marker of distensibility, this may be a precursor to future problems.  In the discussion, the authors note that a 12.5 mm barium tablet test correlates with a 125-mm2 threshold. Thus, their data suggest a corresponding diameter of 17 mm as a prerequisite to avoid food impactions.

Bottomline: this study identifies a new way to assess the risk for food impactions in EoE by measuring esophageal distensibility.

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